Student Doctor Madelyn Pickle OMS I Tubo Ovarian Abscess Student Doctor Madelyn Pickle OMS I

Clinical Presentation CC: Right lower abdominal pain Presenting Sx: pain has worsened in the past 24hrs, spotty vaginal bleeding Patient Hx: 37 yo F Single, sexually active (G2, P0, A2) Trial lawyer Remote cervical cone biopsy (24yo) Mother died of breast cancer at 44yo PE: pale, moderately obese woman. RLQ pain to deep palpation, no rebound tenderness. Labs: mild, normocytic anemia. Elevated BUN and Creatinine Presents to ER, periods have always been painful but advil doesn’t work this time Unknown results of biopsy Information deficits

Differentials1,2 Ectopic Pregnancy Pelvic Inflammatory Disease Tubo Ovarian Abscess Cancer Ruptured Ovarian Cyst Clinical key Medscape Many other possibilities

Labs + Tests 3,4,5 Pregnancy test! STI Pelvic Exam Ultrasound CBC Herpes, Syphilis, HPV Pelvic Exam Ultrasound CBC Vitals Vaginal sample Urinalysis Erythrocyte Sedimentation Rate http://www.meddean.luc.edu/Lumen/MedEd/Radio/Nuc_med/Appendicitis/fluid.htm STI tests, Ask about IUD use = could increase chance of PID Pelvic exam: look for abdominal pain, adnexal tenderness, cervical motion tenderness TOA on US looks like complex adnexal masses w mult internal echoes. Transverse endovaginal US^, also looks like endometrioma or dermoid cyst Leukocytes on wetmount of vaginal culture ESR is nonspecific marker of inflammation that could be assoc w ectopic preg Access medicine, DynaMed, NIH

What is a Tubo Ovarian Abscess? 3,5,6 Pocket of pus from infection of a fallopian tube and ovary Complication of Pelvic Inflammatory Disease or STI Neisseria gonorrhoeae, Chlamydia trachomatis Original infection may be asymptomatic http://www.pathologyoutlines.com/images/ovary/22_61.jpg PID= infection that ascends from the vagina and cervix (Access medicine), most common cause of death from PID is ruptured ovarian abscess. Not all come with PID but 1/3 of women hospitalized for PID have a TOA Sexually transmitted pathogens such as N gonorrhea facilitate the infection but are rarely isolated from the abscess Starts w gonorrhea and chlamydia but can develop into a mixed organism infection as it progresses (harder to treat) anaerobic microbes predominate Increased risk w multiple sexual partner, sperm transport pathogens to upper genital track ie fallopian tubes Key in TOA is inflammation from fallopian extends into ovarian parenchyma and forms pus Multicystic progression^ eMedicine, NIH

Pathophysiology 5,7 Pathogen enters Inflammatory response = damaged endothelium, edema Tubal blockage promotes abscess formation and bacterial proliferation Polymicrobial Escherichia coli, aerobic streptococci, Candida, Salmonella Aerobic, anaerobic, and facultative species Abscess is an infection containment mechanism of the body Ruptured abscess can lead to sepsis Pathogens sexually transmitted, spread from bowel or appendix infection, surgery, endogenous flora Damaged endothelium loses secretory cells and cilia of fallopian tubes (can’t clear out pathogens and debris) Edema could result in necrosis Predisposal from prior infection UpToDate, NIH

Ruptured Abscess 8 http://www.jpgo.org/2015/11/actinomycosis-of-ovary-resurgence.html Actinomycosis infection – ruptured (sulfur granules characteristic of actinomycosis) Deadly if causes sepsis, requires immediate surgical intervention JPGO

Treatment 3,6,7,9 Antibiotics Drainage Surgical removal Clindamycin Metronidazole w/ Doxycycline Anaerobes & facultative Drainage Surgical removal “small” (less than 9cm) abscesses usually resolve with only antibiotics (UpToDate) Oral clindamycin 450mg PO 4 times a day (access med) Clindamycin for most infections, M&D for anaerobes or facultative such as candida (drugs.com) US guided drainage w needle Surgical removal of infected tube and ovary eMedicine

Patient Education 3,7,9 Predisposing risks Follow up 72 hrs STIs, IUD, HIV Follow up 72 hrs Clindamycin Finish antibiotics “safe sex” techniques to avoid re-infection Maintain abstinence for at least 1 week post treatment Fertility Notify sexual partners HIV more susceptible to TOA 72 hrs and no improvement return for CT and maybe drainage, onset of abdominal distention could mean bleeding or ruptured abscess Clindamycin can cause diarrhea, return if watery or bloody Could affect fertility, especially with surgical removal Notify any partners form the past 60 days bc risk of N gonhorrea or chlamydia trachomatis UpToDate, drugs.com, Access med

Bibliography Predictors of tuboovarian abscess in acute pelvic inflammatory disease.Halperin R, Svirsky R, Vaknin Z, Ben-Ami I, Schneider D, Pansky M - J Reprod Med - January 1, 2008; 53 (1); 40-4. Accessed Feb. 1, 2016. Imaging in PID and TOA. Medscape. http://emedicine.medscape.com/article/404537-overview. Published Feb. 27, 2015. Accessed Feb. 1, 2016. Shepherd SM, Weiss B, Shoff WH. Pelvic Inflammatory Disease. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com/content.aspx?bookid=1658&Sectionid =109384667. Accessed February 08, 2016. Kruszka P, Kruszka S. Evaluation of acute pelvic pain in women. American Family Physician [serial online]. July 15, 2010;82(2):141-147. Available from: MEDLINE Complete, Ipswich, MA. Accessed February 8, 2016. Osborne NG. Tubo-Ovarian Abscess: Pathogenesis and Management. Journal of the National Medical Association. 1986;78(10):937-951. Marshall, Sarah. Pelvic Inflammatory Disease: Tubo Ovarian Abscess. eMedicine Health Website. http://www.emedicinehealth.com/pelvic_inflammatory_disease_tubo- ovarian_abscess-health/article_em.htm Published Oct. 30, 2012. Accessed Feb. 8, 2016. Clinical key Medscape Access medicine Dynamed NIH eMedicine

7. Beigi, Richard H. Epidemiology, clinical manifestations, and diagnosis of tuboovarian abscess. UpToDate. Jun 3, 2015. Accessed Feb 8, 2016. Shah NH, Khambati B, Paranjpe SH, Shah VN. Actinomycosis of Ovary - Resurgence JPGO 2015. Volume 2 Number 11. 2015. Available from: http://www.jpgo.org/2015/11/actinomycosis-of-ovary-resurgence.html Accessed Feb 8,2016. Clindamycin. Cerner Multum, Inc. http://www.drugs.com/clindamycin.html Version 9.02 Revised Aug 19, 2014. Accessed Feb 8, 2016. Velcani A, Conklin P, Specht N. Sonographic features of tubo-ovarian abscess mimicking an endometrioma and review of cystic adnexal masses. Journal of Radiology Case Reports. 2010;4(2):9-17. doi:10.3941/jrcr.v4i2.133. 7. UpToDate 8. JPGO 9. drugs.com